Safety and efficacy of dual versus triple antithrombotic therapy (DAT vs TAT) in patients with atrial fibrillation following a PCI: a systematic review and network meta-analysis

Abstract

ObjectiveCreating an appropriate antithrombotic therapy for patients with atrial fibrillation (AF) who have undergone percutaneous coronary intervention (PCI) remains a dilemma. Several clinical trials compared the use of a dual antithrombotic therapy (DAT) regimen with a direct oral anticoagulants including (apixaban, dabigatran, edoxaban or rivaroxaban) and a P2Y12 inhibitor versus a triple antithrombotic therapy (TAT) that includes a vitamin K antagonist plus aspirin and a P2Y12 inhibitor in patients with AF who have undergone PCI. However, there are no head-to-head trials comparing the DAT regimens to each other. We aimed to compare the efficacy and safety of DAT regimens using a network meta-analysis (NMA) approach.DesignA systematic review and NMA of randomised clinical trials.MethodsWe conducted a systematic literature review to identify relevant randomised clinical trials and performed a Bayesian NMA for International Society on Thrombosis and Haemostasis (ISTH) major or clinically relevant non-major (CRNM) bleeding, all-cause mortality, stroke, myocardial infarction (MI) and stent thrombosis outcomes. We used NetMetaXL V.1.6.1 and WinBUGS V.1.4.3 for the NMA and estimated the probability of ranking the treatments based on the surface under the cumulative ranking curve.ResultsThe comparison between DAT regimens showed no significant difference in the safety or efficacy outcomes. Apixaban regimen was ranked first as the preferred therapy in terms of ISTH major or CRNM bleeding and stroke, with a probability of 52% and 54%, respectively. Rivaroxaban regimen was the preferred therapy in terms of MI and stent thrombosis, with a probability of 34% and 27%, respectively. Dabigatran regimen was ranked first in terms of all-cause mortality, with a probability of 28%.ConclusionThe DAT regimens are as safe and effective as TAT regimens. However, ranking probabilities for the best option in the selected outcomes can be used to guide the selection among these agents based on different patients’ conditions.

Antithrombotic Therapy in Patients With Atrial Fibrillation and Coronary Artery Disease With Recent or Remote Events: Systematic Review and Meta-analysis

“…1 ). 12 , 13 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 All meta-analyses except for one Cochrane review 26 were ranked as having low or critically low quality levels according to the AMSTAR 2 criteria ( Supplemental Table S1 ). The high-quality Cochrane review compared DOACs to VKAs post-PCI, which was not a focus for this review.…”

Efficacy and safety of direct oral anticoagulants with and without Aspirin: A systematic review and Meta-analysis

“…Also, in our meta -analysis, results from studies using various types of DOACs were pooled together on the assumption that all DOACs are comparable in terms of safety and efficacy. However, this may not be true as demonstrated by Altoukhi et al [21] study which ranked the different types of DOACs as per their efficacy and safety. In Ruiz et al, out of the 145 patients who received concomitant antiplatelet therapy, 79 percent of them used ASA whereas 21 percent of them were given P2Y12 inhibitor, hence the results of this study do not solely reflect the safety and efficacy of ASA alone but rather the antiplatelet therapy in general.…”

Combination of antiplatelet and anticoagulant therapy, component network meta-analysis of randomized controlled trials

“…Head-to-head comparisons are not available regarding different DOACs in cases of AF patients undergoing PCI. A recently published NMA found that as part of the DAT apixaban was ranked first as the preferred therapy in terms of major or clinically relevant non-major bleeding and stroke, rivaroxaban ranked first as the preferred therapy in terms of MI and stent thrombosis, while dabigatran ranked first as the preferred therapy in terms of all-cause mortality ( 36 ). Various DOACs may have different risk-benefit profiles in combination strategies ensuring implementation of an optimal individualized antithrombotic regimen for patients receiving long-term OAC and undergoing PCI ( 35 , 36 ).…”